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Journal of the Dermatology Nurses' Association:
doi: 10.1097/JDN.0b013e31821e261d
DEPARTMENTS: Abstracts

Poster Abstracts From the Dermatology Nurses' Association (DNA) 2011 Annual Convention

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INFORMATIONAL POSTER ABSTRACTS

"But Doctor I've Used That for Years…." Educating Your Patients Once Diagnosed With an Allergic Contact Dermatitis

Presenters: Cynthia Alcorn, RN, Donalda Dwyer,RN, Jordyn Foy, RPN

INTRODUCTION: Many patients are in disbelief that a product that they have been in contact with or used for many years is the source of their allergic contact dermatitis. Thus, the challenge begins as their healthcare practitioner. Two questions you ask yourself while facing this challenge are, "How does the healthcare practitioner address these challenges?" and, "How does the healthcare practitioner encourage their patients to become critical thinkers?"

METHODS: The method to compile the essences of our information was holding brainstorming sessions among the nurses who conduct the patch clinic for Dr. Melanie Pratt at the Ottawa Hospital. A literature search was done to assist in defining the types of contact dermatitis (irritant or contact) as well on adult learning and teaching methods.

RESULTS: It is well documented that allergic contact dermatitis can be resolved with avoidance of the source. Giving the patients the tools on how to avoid the source is the key. Patient education and understanding are the foundation.

CONCLUSION: Education, repetition, reinforcement, and encouragement are all vital to instill trust and confidence from the patients' perspective to achieve their "buy in" about what they are being told. The real rewards come when their aesthetic appearance and symptomatic relief have returned in part because their actions follow what has been suggested from the outcome of the testing results.

NURSING IMPLICATIONS: The importance of education and teaching as vital components of the nursing process has been recognized since the early days of the profession (Kovner & Jones, 2002). The role of nurses is to provide patient education to the patients undergoing patch testing so that we may find the source for the allergic contact dermatitis, and this is accentuated in this clinical setting. The patients have committed a week of their time and must follow many dos and don'ts to maximize the effect of this testing procedure. Having a patient understand and comply with the direction they received is a demonstration that the nursing process has been effective. For nurses, this is very reflective of our practice when evaluating the outcomes.

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REFERENCES

Canada's National Occupational Health and Safety Resource Dermatitis, Allergic Contact, from http://www.ccohs.ca

Canada's National Occupational Health and Safety Resource Dermatitis, Irritant Contact, from http://www.ccohs.ca

Contact Dermatitis, from http://www.uptodate.com

Contact Dermatitis Canadian Dermatology Association

Patient Education and the Nursing Process: Meeting the Patient's Needs, from http://findarticles.com

Practical Tips for Patient Teaching, from http://findarticles.com

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Prevention of Wrong Site Surgery: Protocol in Surgical Dermatology, Mayo Clinic Arizona

Presenters: Jenny Kevric, LPN, Shari Nemeth, MD, Kathy Gross, RN, BSN

INTRODUCTION: This poster will review the potential risk of wrong site skin cancer surgery, the reasons for the risk, and a workflow that allows minimal error.

METHODS: Data were assembled by reviewing literature. We then critically analyzed our workflow for ways to decrease the risk for error.

RESULTS: Dermatology patients have severely photo-damaged skin. Many have history of multiple biopsies, cryosurgery, chemotherapy, and cutaneous malignancy surgeries. As we attempt to identify the correct biopsy site, we face a potential risk for performing surgery on the wrong site. This risk is heightened in the many patients who are referred with no photographs of the biopsy site. In addition, cognitive impairment in older people can lead to poor recall of the biopsy site. Review of data and workflow resulted in several steps being added.

CONCLUSION: When examining the fact that dermatologic surgeons perform, on average, 3.9 million surgeries, one must consider the potential risk for wrong site surgery. Making photography of biopsied lesions mandatory in our workflow decreases that risk significantly.

NURSING IMPLICATIONS: The nursing staff participate as active members of the medical team, ensuring that the potential for wrong site surgery is minimized.

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REFERENCE

Shari Nemeth, MD. The Risk of Wrong Site Surgery and the Mohs Surgeon, 2010 Mohs College Annual Meeting.

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The Mohs Surgery Nurse's Role in Patient Education; Related to Wound Care of the Paramedian Flap

Presenters: Anne Hansen, RN, BScN, Melissa Nicastro, RN, BScN, Gail Gamble, RN

INTRODUCTION: The poster will discuss the nurse's role in patient education related to wound care of the paramedian flap. Most Mohs clinics refer these patients to plastic surgery, and the procedure is performed in an operating room with anesthesia present, due to the size of the wound and depth, as nasal cartilage is exposed. The poster will include our wound care information and the stages of healing using photographs.

METHODS: Detailed patient assessments and education preoperative, intraoperative, and postoperative have proven to be an asset. The development and use of preoperative assessment documents and patient education documents have proven to be a positive factor in patient understanding and wound care postoperative.

RESULTS: Photographs taken of each stage of the healing process show how these large incisions heal with no increase in infection rate or scarring compared with the average Mohs surgical patient. The patient is also not compromised by IV or general anesthesia in the recovery period.

CONCLUSION: The nurse plays a key role with her initial assessments and ongoing education throughout the patient's stay in the Mohs unit. Detailed take home instruction sheets on care of the surgical site promotes an optimum environment for wound healing.

NURSING IMPLICATIONS: The hiring and training of the Mohs nurse and the development and use of the specialized patient education sheets are the key to positive outcomes in the healing of these paramedian flaps.

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Understanding REMS: A Training Program for Nurses

Presenters: S. Risley, J. Vanak, N. Rayhorn, T. Mefford, M. Smith, RN, H. Fuchs-Crosby

INTRODUCTION: The Food and Drug Administration Amendment Act (FDAAA), passed in 2007, gives the authority to mandate a Risk Evaluation Mitigation Strategy (REMS) if it is determined necessary to ensure that the benefits of a drug or biological product outweigh the risks. REMS programs are now used to manage a known or potential serious risk associated with a drug or biological product and are a critical element of pre- and post-approval plans. Currently, over 140 drugs and biologics have REMS in place. All REMS programs include a patient education element, which is frequently delivered by a nursing personnel. The Centocor Ortho Biotech Nursing Council (COBNC) consists of registered nurses with extensive and diverse backgrounds (e.g., oncology, nephrology, rheumatology, gastroenterology, and dermatology). The goal of this group is to identify and address scientific needs in the nursing community and ultimately improve quality of care.

METHODS: An extensive literature search was conducted that revealed a paucity of information about REMS that is directed specifically toward nurses. A REMS education training program was developed. Twenty-five nursing professionals completed the training, which included a description of the basic components of a REMS and resources for patient education. In addition, information was provided on how to report an adverse event (AE). A pre- and post-knowledge assessment was completed using the ZOOMERANG® survey tool.

RESULTS: Of the 25 respondents, 77% were registered nurses, 15% were nurse practitioners, and 8% were clinical nurse specialists. Most of those interviewed were from community-based practices, followed by academic settings and infusion centers; the most common primary responsibility was direct patient care. Among respondents, 77% had not heard about REMS, and 69% had never reported an AE. After training, 81% reported that the information would positively impact future patient care, whereas 19% reported that the information would be unlikely to impact their practice. Seventy-five percent of respondents indicated that the information would benefit the delivery of patient education. Overall, 92% reported that they would be able to recognize and report an AE to the FDA.

CONCLUSION: A nursing council or advisory team within a company can provide key insights specific to the needs of nurses and develop strategies to support the nursing community, such as REMS education and AE reporting. REMS training directed toward nurses may improve patient care and delivery of patient education.

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Photoresponsive Diseases

Judith Pitman, RN, Gabriele Muekusch, RN, Elmira Almaniyazova, RN

INTRODUCTION: This colorful poster was designed as an educational tool for patients with photoresponsive diseases. Our aim is to promote health teaching and awareness. It is presented in an easy-to-read point form with quality images.

METHOD: Information was compiled from Dermatology (Bolognia, Jorizzo, & Rapini, 2003) and a search of the literature to check that information is still accurate.

CONCLUSION: By reviewing this poster, patients and family members will gain an understanding of the diseases that respond to phototherapy.

NURSING IMPLICATIONS: This informational poster will be displayed in our clinic. Our hope is that this will prompt patients to ask more appropriate and specific questions regarding their healthcare.

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REFERENCE

Bolognia, J., Jorizzo, J., & Rapini, R. (2003). Dermatology. Edinburgh: Mosby.

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The Nurse Practitioner and the Dermatologist-An Innovative Practice Management Model for Effective Delivery of Care

Presenters: Melodie S. Young, MSN, RN, ANP-C, Jennifer C. Cather, MD

INTRODUCTION: Limited data are available about relationships between nurse practitioners and dermatologists. Approximately 10% of dermatology practices included nurse practitioners in 2007, and this number is expected to rise, indicating the need for relevant nurse practitioner or dermatologist practice models.

METHODS: Here we introduce and demonstrate an innovative and effective practice management and research model, led by a close partnership between a nurse practitioner and a dermatologist.

RESULTS: We have developed a thriving dermatology practice, leveraging the skills and talents of a variety of dermatology health professionals to serve an ethnically and socioeconomically diverse patient population across the spectrum of dermatologic concerns from cosmetic procedures to the management of chronic immune-mediated diseases. In addition, our research division explores investigative therapeutic agents using the same complementary and collaborative partnership.

CONCLUSION: This unique practice and research model offers a financially successful and professionally fulfilling, real-world example to nurse practitioners seeking to leverage their unique approach to both care and cure through clinical care, health promotion, disease prevention, health education, and counseling in private practice and research.

NURSING IMPLICATIONS: Nursing professionals can use this model as an example of successful partnership with a dermatologist.

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REFERENCES

Kimball, A. B. & Resneck, J. S. Jr. (2008). The US dermatology workforce: A specialty remains in shortage. Journal of the American Academy of Dermatology, 59(5), 741-745. >Epub 2008 Aug 23>.

Resneck, J. S. Jr. & Kimball, A. B. (2008). Who else is providing care in dermatology practices? Trends in the use of nonphysician clinicians. Journal of the American Academy of Dermatology, 58(2), 211-216.

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RESEARCH POSTER ABSTRACTS

Cost and Effectiveness Evaluation of Hydrogel 2% on Leg Ulcer Treatment

Presenters: Beatriz Guitton Renaud Baptista de Oliveira, Luciana Miranda Rodrigues, Glycia de Almeida Nogueira, Selma Rodrigues Castilho, Debora Omena Futuro

Federal Fluminense University, 2010

This study aimed to (1) evaluate the effectiveness of hydrogel 2% in patients with leg ulcers based on lesion evaluation, (2) estimate the average cost of using the hydrogel 2% in patients with leg ulcers within 90 days, and (3) compare the cost of the use of hydrogel 2% with other commercially available hydrogels. This is a study of a therapeutic intervention, a prospective clinical trial, uncontrolled on evaluating the use of hydrogel 2% produced in the pharmacy college in the treatment of wounds in patients with leg ulcers. The sample consisted of 20 male and female volunteers, and 16 volunteers fit the inclusion criteria during the 90 days of treatment with hydrogel 2% with 250 consultations during the period of February to October 2010. This study was submitted to the Committee on Research Ethics at the University Hospital on advice CAAE 0154.0.258.000-08, and the terms of consent and photography are in accordance with Resolutions 196/96 and 251/97 of the National Health Council. Of this sample group, 62.5% of the volunteers were predominantly women. The mean age ranged from 11.4 ± 60.5 years, and 93.75% of the patients have arterial hypertension, diabetes mellitus, or other chronic diseases. On the analysis of the clinical outcome of leg ulcers, it was observed that two distinct groups emerged with respect to the size of the lesion area, which are classified in this study as Area 1, for lesions with size over 100 cm2 (39.37 in2), and Area 2, for lesions with size below 100 cm2 (39.37 in2). It was noted that the tissue with the highest prevalence at baseline was the tissue devitalization, which involved an average of 3.75 ± 1.2 of the wound bed. After 90 days of treatment with hydrogel 2%, the tissue showed important changes to healing and /or reduction area lesion (p = .0416). The presence of granulation tissue began to prevail with an average of 3.12 ± 1.0 and 25% of these volunteers with total healing (100% epithelization tissue). On the cost analysis with hydrogel 2% treatment, the ulcers belonging to Area 1 (over 39.37 in2) were higher than those belonging to Area 2 (below 39.37 in2), and this variation was by U.S.$8.63 to Area 1 and by U.S.$25.80 to Area 2.

When comparing the treatment of leg ulcers as hydrogel 2% (100 g) to commercially available hydrogels in proportionate amounts to 100 g, there was a significant difference (p = .0003) from the values related to Areas 1 and 2 in all perspectives of the study. Area 1 had a variation in price from U.S.$66.38 to U.S.$536.53, and Area 2 ranged from U.S.$41.61 to U.S.$328.75 on three perspectives of study.

CONCLUSIONS AND NURSING IMPLICATIONS: After analyzing using this therapy, it was found that hydrogel 2% shows a significant efficacy, and its low costs justifies its use in the public health services. The hydrogel 2% manipulated in a pharmacy college represents an alternative to this situation, because it promotes improved healing rates, decreased treatment time of these ulcers, as well as being a low-cost treatment, as compared with other commercially available hydrogels in the local market, bringing lower costs to health services. The joint work of the teachers of the School of Nursing and pharmacy researchers is aimed at healthcare for poor people with injuries and has presented positive results and lower cost.

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Lesion Identification by Primary Care Nurse Practitioners

Pamela K. Fletcher, DNP, DCNP, FNP-C, Margaret A. Bobonich, DNP, DCNP, FNP-C, FAANP

INTRODUCTION: One person dies nearly every hour in the United States from malignant melanoma. An estimated 68,130 people will have been diagnosed with deadly invasive malignant melanoma in 2010, and 8,700 will die. Rates of malignant melanoma are increasing, especially among younger populations. Prevention is the ideal, and early diagnosis can greatly increase chances of survival. Malignant melanomas discovered by primary care physicians were thinner (early stage) and easier to treat than those recognized by the patient or family. Malignant melanoma is curable if recognized and treated in the early stage; 5-year survival rates are 98%. Primary care nurse practitioners (PCNPs) are strategically positioned in the healthcare system and uniquely trained to provide prevention and risk reduction education to patients, as well as early diagnosis and treatment of disease. The shortage of dermatology providers increases the imperative for primary care providers to become proficient in recognizing this dangerous skin cancer, yet few studies have been done to examine the readiness of PCNPs to provide these life-saving services.

METHODS: The Nurse Practitioner Survey of Dermatological Assessment examined, in part, the ability of PCNPs to recognize benign, premalignant (dysplastic), and malignant skin lesions through the use of photos. Benner's theory of novice to expert served as the framework for the study. Participants were selected from members of the American Academy of Nurse Practitioners, including a random sample that completed the survey on-line as well as a convenience sample attending a specialty conference.

RESULTS: There were a total of 156 participants from 32 states. Only 58% correctly identified both malignant melanoma photos. Respondents had more difficulty with recognizing the benign and dysplastic lesions. The two photos of dysplastic nevi were identified incorrectly by 83% and 86% of PCNPs. Participants were 32% and 62% incorrect on two pictures of benign nevi and 86% and 70% incorrect on two pictures of seborrheic keratoses.

CONCLUSIONS: PCNPs demonstrated an adequate ability to identify malignant melanoma from photos. However, they had much greater difficulty in correctly identifying dysplastic nevi, which can be precursors to malignant melanoma. They also had difficulty recognizing benign lesions (nevi and seborrheic keratoses).

NURSING IMPLICATIONS: PCNPs may need additional education and clinical experience in order to develop competency in differentiating malignant, precursor, and benign lesions of the skin. It is imperative that this be provided so that they can fulfill the vital role of reducing morbidity and mortality from malignant melanoma.

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REFERENCES

Altekruse, S. F., Kosary, C. L., Krapcho, M., Neyman, N., Aminou, R., Waldron, W., et al. (Eds.). (2009). SEER cancer statistics review, 1975-2007. Bethesda, MD: National Cancer Institute. Retrieved from http://seer.cancer.gov/csr/1975_2007/

Benner, P. (2004). Using the Dreyfus model of skill acquisition to describe and interpret skill acquisition and clinical judgement in nursing practice and education. Bulletin of Science, Technology & Society, 24(3), 188-199.

Cassileth, B. R., Clark, W. H. Jr., Lusk, E. J., Frederick, B. E., Thompson, C. J., & Walsh, W. P. (1986). How well do physicians recognize melanoma and other problem lesions? Journal of the American Academy of Dermatology, 14(4), 555-560.

Furfaro, T., Bernaix, L., Schmidt, C., & Clement, J. (2008). Nurse practitioners' knowledge and practice regarding malignant melanoma assessment and counseling. Journal of the American Academy of Nurse Practitioners, 20(7), 367-375.

Maguire-Eisen, M., & Frost, C. (1994). Knowledge of malignant melanoma and how it relates to clinical practice among nurse practitioners and dermatology and oncology nurses. Cancer Nursing, 17(6), 457-463.

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Tracking Use of UVA-1 in the Psoriasis and Phototherapy Clinic Skin Care Center, Vancouver General Hospital

Judith Gerbrandt,Sunil Kalia, Jennifer Howe, MD, MCR, Kurt Pachal, Elaine Stebbing,Martina Slezkova, Martin Tsai, Helena Yang, Soodabeh Zandi, Harvey Lui

INTRODUCTION: Ultraviolet radiation is an important modality for treating various skin disorders. Longer wave ultraviolet light, in the UVA region, has a greater capacity to penetrate the dermis, which makes UVA-1 phototherapy potentially effective for treating sclerosing skin conditions. This poster will review patient demographics and diagnoses selected for treatment in our clinic. The unique dosimetry and treatment course will be analyzed along with patient challenges and outcomes.

METHOD: A chart review was conducted on the patients' records that received UVA-1 treatment daily for four consecutive weeks, during the period from November 1, 2009 to November 30, 2010. A multilateral UVA-1 ML24000 phototherapy chamber manufactured by Daavlin Distributing Company was used for treatment. Efficacy was evaluated after 20 treatments and at 2-month intervals thereafter.

RESULTS: Data were compiled from 13 patient charts. Ten patients were able to tolerate our designated start dose (60 J/cm2) throughout the full course of treatment, two required dosage adjustment, and one was unable to complete a full treatment course. One patient has undergone a second course of treatment at a higher fluence of 130 J/cm2. The effects of treatment varied between patients and diagnoses. Diagnoses varied from morphea (8), scleroderma (2), lichen sclerosis (1), mastocytosis (1), to eosinophilic fasciitis (1). Ten female and three male patients were evaluated. Their ages ranged from 17 to 61 years. Results, other than deep tanning, were rarely immediate; patients were more likely to report evidence of skin softening and clearing in follow-up visits approximately 2-4 months after the treatment session had ended.

CONCLUSIONS: UVA-1 treatment appears to be of value to patients whose skin disease is of a deeper nature than those affecting only the epidermis. Sufficient data have been collected to formulate a patient information and education handout.

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A Body Wash and Moisturizer With Filaggrin Breakdown Products Improves Hydration and Skin Barrier Function in Infants and Toddlers at Risk for Atopic Dermatitis

Presenters: Eric L. Simpson, MD, MCR1, Nathan Trookman, MD2, Tu T. Huynh, PhD3, Anita Zacherl, RN, RAC3, Ronald W. Gottschalk, MD, FRCPC3

1Associate Professor of Dermatology and Director of Clinical Studies, Oregon Health and Science University, Portland, OR, USA. 2Stephens and Associates, Inc., Colorado Springs, CO, USA. 3Galderma Laboratories, L.P., Fort Worth, TX, USA

INTRODUCTION: A body wash and moisturizer containing filaggrin breakdown products and ceramides were developed specifically for use in patients with atopic dermatitis (AD).

METHODS: A study was conducted to assess safety, tolerability, hydration, and skin barrier function of these products in infants/toddlers with atopic skin.

RESULTS: Hydration was significantly increased compared with baseline at Weeks 2 and 4 on both the forearm (p < .0001) and the lower leg (p < .0001). Skin barrier function was improved compared with baseline at Week 2 (p = .0139) and Week 4 (p = .0091). Most patients had no edema (98% with none), scaling or dryness (85% with none), or rash (100% with none). Half of the patients also had no erythema. Eight patients experienced adverse events that were considered related to the study products (application site irritation or rash, scalp itch, and stinging or burning in eyes).

CONCLUSIONS: A daily regimen of skin restoring body wash and moisturizer increases hydration and helps repair the skin barrier in children as young as 3 months old with atopic skin. The regimen was well tolerated.

NURSING IMPLICATIONS: Nurses are often the healthcare professional advising patients on nondrug aspects of care such as cleansing or moisturizing. These data provide nurses with information regarding skin care products for their patients with atopic dermatitis.

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Ustekinumab Safety Update: Cumulative Experience From Longer-Term Follow-up of Patients Treated in the Ustekinumab Psoriasis Clinical Development Program

Presenters: K. Gordon1, C. Leonardi2, C. E. M. Griffiths3, P. O. Szapary4, K. Reich5

1University of Chicago Pritzker School of Medicine/NorthShore University Health System, Chicago, IL, USA. 2Department of Dermatology, St. Louis University, St. Louis, MO, USA. 3University of Manchester, Manchester, UK. 4Centocor Research and Development, Inc., Malvern, PA, USA. 5Dermatologikum Hamburg, Hamburg, Germany

OBJECTIVE: The objective is to analyze the cumulative safety experience and select adverse events observed across psoriasis clinical trials in patients treated with ustekinumab (UST), a first in class, human monoclonal antibody against interleukin 12/23p40.

METHODS: This analysis pooled safety data across Phase 2 and Phase 3 psoriasis trials including 152 weeks (3 years) from PHOENIX 1, 100 weeks (2 years) from PHOENIX 2, and 64 weeks (1 year) from ACCEPT (n = 903). UST at 45 mg and 90 mg dosing was studied in each trial (Phase 2: one injection or four weekly injections; PHOENIX 1 and 2: injections at Week 0, Week 4, and q12wk thereafter. Placebo-treated patients crossed over to UST at Week 20 (Phase 2) or Week 12 (PHOENIX 1 and 2). In ACCEPT, patients received injections at Weeks 0 and 4 and at variable intervals thereafter. All analyses are adjusted for follow-up and expressed as rates per 100 patient-years (PY) of exposure.

RESULTS: This analysis included 3117 patients (4782 PY of follow-up), with 1247 patients treated for at least 2 years (median follow-up = 1.7years). Overall AE rates per 100 PY were 287.75 and 280.29 for the UST 45mg and UST 90mg groups, respectively. The most common reported AEs (≥5%) included nasopharyngitis, upper respiratory tract infection, arthralgia, sinusitis, headache, and back pain. The rates of serious AEs per 100 PY were 6.78 and 8.24 for each group, respectively. Serious infection rates per 100 PY in the UST 45 mg and UST 90 mg groups were 0.82 and 1.50, respectively; rates of infections requiring treatment were 34.9 and 34.7 per 100 PY, respectively. The incidence of nonmelanoma skin cancers (NMSC) per 100 PY of follow-up in UST 45 mg and UST 90 mg groups were 0.64 and 0.77, respectively. Rates of noncutaneous malignancies were 0.69 and 0.46 for the respective UST dose groups. Rates of major cardiovascular events (cardiovascular death, myocardial infarction, or stroke) per 100 PY in the UST 45 mg and UST 90 mg groups were 0.41 and 0.35, respectively. Rates of serious infections, malignancies, and major cardiovascular events were stable over time and were consistent with rates previously described and with observations in the general and/or psoriasis population.

CONCLUSIONS: The safety profile of continued UST exposure in the most recent pooled analysis is favorable and is consistent with previous reports. Ongoing Phase 3 studies with a total of 5 years of follow-up will continue to define the safety profile of UST in the psoriasis population.

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Dermatology Nurses' Association Poster Award Winners

INFORMATIONAL

1st Place

Susan Risley, BSN, MAOM, ETN

Understanding REMS: A Training Program for Nurses

2nd Place

Cynthia Alcorn, RN

"But Doctor I've Used That for Years…."-Educating Your Patients Once Diagnosed With an Allergic Contact Dermatitis

RESEARCH

1st Place

Pamela Fletcher, DNPc, APRN-BC

Lesion Identification by Primary Care Nurse Practioners

2nd Place

Beatriz Guitton

Cost and Effectiveness Evaluation of Hydrogel 2% on Leg Ulcers Treatment

© 2011 Lippincott Williams & Wilkins, Inc.

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